Millennium Risk Managers
Claims Administration
QUALITY ASSURANCE
Millennium Risk Managers employs approximately 32 individuals that encompass legal staff, claims administration staff, accounting staff, technical assistant staff and administration staff.
Millennium Risk Managers conducts internal claims audits on a monthly basis by the Senior Claims Administrators of each department to verify that all claims administration benchmarks are maintained for each client. This internal audit process is designed to identify any flaws within the claims administration system including the medical bill adjudication system prior to any outside audit. Each file is designed and maintained for the purpose of easy outside audit accessibility.
Tom Roper, of Millennium Risk Managers has identified, through the past 16 years, which vendors produce the best results depending upon the specific fact situation confronting the employer. It is important to note that Tom Roper will make recommendations to the account for vendor selection and the account will make the final selection of vendors to be utilized for the employer’s program. Tom Roper has full knowledge of the judges that will hear each case in all counties in the State of Alabama and knows which attorneys have the best rapport with the particular judge that is hearing the claim as well as which attorneys have the highest quality of litigation experience to give the best representation to MRM’s accounts.
Millennium Risk Managers knows which case management nurses have the best rapport with the medical vendors operating within a specific geographic region within the State of Alabama.
Most importantly, Tom Roper knows which private investigating firms have quality individuals with quality staffing and quality equipment to provide optimum results for the client when surveillance is necessary to combat an over exaggerated claim or a malingering claimant.
The attorney vendors, the surveillance vendors and the case management vendors all must have a Certificate of Insurance on file with Millennium Risk Managers that has a minimum of $1,000,000 in E&O insurance and the account must be listed as an additional insured prior to the vendor being allowed to obtain any business from Millennium Risk Managers on behalf of the client.
The Senior Claims Supervisors conduct a 15 area internal claim audit on internal files monthly to ensure that all of the “Best Practices” are being maintained on a consistent basis.
All adjusters must attend a minimum of eight (8) hours of outside training per year. All adjusters are licensed with the State of Alabama Department of Industrial Relations.
The in-house attorneys must attend a minimum of twelve (12) hours per year of continuing legal education and generally, on average, have 24 hours of continuing legal education.
All management staff must attend at least two (2) management training seminars per year.
In regards to all other support personnel, if a manager identifies a problem with an employee working for the manager, the manager have been given specific authority to sign up the employee for any and all outside courses to assist in enlightening and giving to the employee, the necessary tools to perform the job task to the standards expected by Millennium Risk Managers.
STAFFING
Millennium Risk Managers believes in a team concept that encompasses the entire claims administration process. This team concept envisions the account having as much input into all aspects of the decision making process as determined by the account. For example, Group Fund Administrators are given the opportunity to participate in the interviewing and hiring process of the adjusters that are dedicated for that particular group pool and they also participate in salary ranges for senior claims staff positions that are dedicated to that particular group pool.
ADJUSTER CASE LOAD CAPACITY
Millennium Risk Managers establishes a maximum caseload benchmark per adjuster of 275 files for a medical only adjuster and 150-170 files for a lost time adjuster. Each adjuster has a technical assistant assigned to assist in all claims administration issues on behalf of the adjuster.
CLAIMS INVESTIGATIVE PROCESS
Each lost time file is reviewed by the Millennium Risk Managers’ General Counsel prior to the assignment of the case to the designated adjuster. This initial legal review is conducted to provide initial instructions to the adjuster and it provides an initial legal review based upon the fact situation as to the compensability of the claim or compensability questions of the claim as it relates to the Alabama workers compensation Statute and current Supreme Court decisions which have been handed down interpreting the specific sections of the Alabama workers compensation Statute. This is critical in Alabama to have each file reviewed by an attorney that is specialized in only workers compensation law and this review provides a “safety zone” for the potential denied claim as it relates to outrageous conduct lawsuits in the State of Alabama.
After the initial legal review and the identification of a potentially fact situation which justifies a full denial of benefits or a particular denial of benefits, Millennium Risk Managers’ policy is to retain (on behalf of the client) a private investigator to take an onsite statement of all witnesses and the claimant at the very outset of the claim. This is critical that the statement process be conducted by an outside source (for an unbiased statement taking process to eliminate the credibility issue in the event of trial) and at the very beginning so that the claimant cannot, at a later point, come up with a new fact or a new body part that he or she claims was involved in the work comp incident. Employees who are experienced at malingering understand that as the authorized treating physician is about to place the employee at maximum medical improvement they will (1) identify to the doctor a new part of the body that is now involved and (2) request a panel of four physicians in an attempt to remain off work. It is the initial statement process that is utilized by Millennium Risk Managers to combat the migration of the injury with a new doctor.
Once the medical records are obtained and the statements are obtained, Millennium Risk Managers is in a position to make a recommendation to the client as to whether the claim should be accepted or denied in full or partially and the client will make the final decision based upon the recommendation of Millennium Risk Managers.
AUTHORITY LEVEL
The client designates Millennium Risk Managers’ authority level; however, it is our recommendation that no authority level be given to any third party administration company and that the account be involved in every decision in settlement, mediation and litigation decisions.
When a case is at the point that a settlement or a resolution is appropriate (whether it be non-litigated or litigated, the adjuster makes a written recommendation to Millennium Risk Managers’ General Counsel who reviews the recommendation for all appropriate values and defenses. The General Counsel and the adjuster will then make a written request for settlement to the client and in this request, the client is given the ceiling value (highest exposure) and the floor value (lowest exposure) together with all appropriate events and medical treatment with all medical ratings and impairments to the client which indicates a value if the claimant is allowed to return back to some form of employment or if the claimant is unable to return to some form of employment with the client. This gives the client the ability to make a financial decision as to whether or not to accommodate the employee as it relates to the employee returning back to work.
If the client approves an authority level of settlement for these specific claims, the adjuster will make a initial minimum offer to the claimant, in writing, and carbon copy to the client’s representative; however, in the event the claimant is represented by an attorney but no lawsuit has been filed against MRM’s client, the General Counsel of Millennium Risk Managers will make the initial written offer to the claimant’s attorney and will enter in all negotiation to resolve the claim.
In the event litigation has been instigated by the claimant, Millennium Risk Managers will have the entire workers compensation file together with an appropriate detail analysis cover letter sent to The account’s designated litigation counsel so that all pertinent facts and defenses are brought to The account’s litigation attorney at the outset of the litigation process.
Generally all litigated cases are court ordered to mediation. Tom Roper attends all mediations on behalf of MRM’s clients notwithstanding that the client’s litigation counsel is participating in the mediation process. This is an important feature of Millennium Risk Managers’ services because Tom Roper has ten years litigation experience on the plaintiff’s side and sixteen years of negotiation experience and mediation experience on behalf of the employers in the State of Alabama. Basically, Tom Roper’s primary job function is negotiating a resolution for MRM’s clients or fighting a fraudulent claim for MRM’s clients and this is a primary reason why Millennium Risk Managers has never lost a client.
NARRATIVE REPORTS
A narrative report is provided for each claim that has a total incurred of $50,000 or more (this report can be initiated at any total incurred level determined by the client; however, it is recommended that the narrative report to be initiated at a $75,000 total incurred point). This report is produced every three months and is vital to loss control, actuaries and pool administrators.
OUTSIDE AUDITORS AND CONSULTANTS
Millennium Risk Managers is a strong advocate in the outside claims audit process. Each file is maintained and designed for the outside audit process and Millennium Risk Managers strongly urges The account Administrator to hire an outside claims audit firm to conduct a claims audit at a minimum of one time a year and preferably two times a year.
Because Millennium Risk Managers is a firm believer that the claims administration process encompasses a team effort (safety staff, human resource staff, legal staff, adjusters, bill adjudicators etc) an outside audit provides a benchmark for the claims team and gives an evaluation to the team and to The account Administrator as to its performance. Most importantly, the outside audit provides to the claims team direction as to whether the team needs to focus to provide optimum results to maintain and establish the financial integrity of the workers compensation exposures pending against The account.
OVERALL POOL RESERVE REVIEW AUDIT
During the month preceding the beginning of a new fund year, MRM’s legal staff and the account’s top administration staff meet over a two to three day period and review every open and reopen claim pending for all years.
During this review, all of the adjuster notes are reviewed by claim together with the outstanding reserves for each reserve type bucket and compare those outstanding reserves to the past twenty four month payments out of each reserve bucket to ensure that we have proper reserve trending and proper reserves established on each file prior to the financials being reported to the actuaries at the beginning of the fund year.
This process is critical to make sure that the reserves maintain a historical level funding as well as to identify trends in cost mechanisms as well as to ensure that the adjusters are properly implementing cost containment programs that have been developed and implemented for the overall pool’s financial integrity.
DIVIDEND CALCULATION AND DIVIDEND RESERVE AUDIT
If the group pool pays dividends, whether it is by check or front end billing discounts, MRM’s software calculates the dividends and MRM’s claim system has the capability of printing off the dividends checks or placing the dividends on the billings as front end billing discounts.
Prior to the calculation of the dividends and the designation of the members who will receive the dividends, MRM undertakes a reserve audit for all open and reopen claims to make sure that the proper loss ratios, by member, are established for the years that the dividends are to be paid from for any given dividend declaration periods.
INTERNAL MODIFICATION FACTOR CALCULATION
Millennium Risk Managers has the software capabilities of computing each fund member’s Modification Factor internally. MRM’s software as well as the timing of data calculations follows NCCI rules and regulations. Correspondingly, we take the data as of the six months preceding the year of calculation and we utilize the loss data for the three years as of that six month snapshot time period as per NCCI’s regulations.
What’s important is that the month preceding the snapshot of the modification three years, we take every open and reopen claim and go through the entire reserve review process to make sure that the proper total incurreds are accurate and properly recorded into the calculation of each members Modification Factor. This ensures the account administrator that the member is paying the proper premium i.e. we do not want to have a file under-reserved and thereby the member pay less premium to the account (this will diminish the overall financial integrity of the account in the long run) and we do not want a file over-reserved (because this will give an unfair marketing advantage to the account’s competitors).
If the account has NCCI calculate the Modification Factors, this same process of reserve reviews are undertaken prior to the electronic submission of data to NCCI.
PREMIUM BILLING AND UNDERWRITING
Millennium Risk Managers’ underwriting team meets with fund administrators and loss control departments approximately two to three months before fund year renewal. We review experience mods, loss history, payment history, safety programs, etc. for each individual fund member to determine discretionary discounts to be applied to each individual fund member.
This process produces a preliminary billing for each member that is based upon accurate loss control information and loss data information. This produces a preliminary billing that assists the fund administrator in making sure that there has been a proper billing for each member to make sure that the members who have implemented strong loss control and good communication on claims that have resulted in excellent loss history by member are maintained in the billing process.
Likewise, it gives the fund administrator a heads up as to which members’ billing for the upcoming year will most likely be out of budget for its members’ financial budgeting process. On these members, where the billing for the upcoming year appears to be potentially out of budget, these bills are taken by Tom Roper to the individual members personally to discuss the billing and to show the member why the billing has substantially increased.
Millennium Risk Managers has a very sophisticated billing system and Millennium Risk Managers inputs all payroll audit information (whether it be secured by self audits or onsite payroll audits) and inputs all payroll data by member by class code together with the appropriate discounts and mod factors that have been derived from extensive preliminary audits and reviews and produces the proper billings which are mailed out by MRM.
MRM records and maintains on its sophisticated billing receipts software all payments that have been received as well as maintains all delinquent members’ status tighter with 30 day cancellation notices as well as official cancellation notices to the fund member, the fund administrator and to the State.
FUND ADMINISTRATOR AND MRM POLICY ADMINISTRATION STAFF MONTHLY MEETINGS
MRM’s Policy Administration staff (which is fully bonded) has extensive training fifteen years experience in payroll coding, billing and excess carrier billing, reporting, collections and electronic reporting to NCCI. If the account reports to NCCI, MRM’s Policy Administration staff has extensive training and in proper electronic reporting to NCCI which is critical as it relates to the participation in reporting to NCCI’s database requirements.
Every month, MRM will meet with the account administrator to go over payroll audit results and statutes as well as final audit billings, collections and delinquencies and go over all current year billings and premium collections.
It is at this meeting each month that the fund administrator reviews, by each member account, the premium delinquency and time of delinquency and authorizes 30 day cancellation notices and actual cancellation notices to which are then implemented by MRM’s Policy Administration staff.
In addition to the above services provided by MRM’s Policy Administration staff, we also provide the following as well:
1. Quotes for incoming members
2. Provides information to the actuaries for rate studies
3. Monitors volume discounts
4. Posting of accounts receivable
5. Depositing of funds
6. Calculation of dividends
CLAIMS REVIEW PROCESS
Millennium Risk Managers is a strong, strong advocate that Millennium Risk Managers’ staff attorney and adjuster meet with the account’s largest participating member’s representative, litigation counsel representative and human resource representatives once a month to review and give claims direction on each and every pending claim against the larger pool members.
This crucial claims meeting is the foundation for concise communication on each specific claim and it provides the foundation for the most important part of the claims process which is bringing together the “claims administration team” philosophy from the account level all the way up to the fund administrator level.
Most importantly, these types of monthly meetings foster a strong faith relationship between the participating member, the group pool administrator and the entire claims administration staff and insures that everyone is working on the same page with the same timely facts.
The claims administration process in the State of Alabama cannot be handed to one entity; rather it is a solid team effort that every member of the team must cooperate and must function as one unit to provide optimum financial stability to any employer in the State of Alabama.
EXCESS CARRIER REPORTING
Millennium Risk Managers’ client administrative staff does all of the reporting requirements to The account’s reinsurance carrier at no additional charge or add on fee.
INSURANCE COMPANY APPROVAL
Millennium Risk Managers specializes in providing TPA services only for employers in the State of Alabama and no one else. Millennium Risk Managers specializes in self insured accounts and the administration of claims exposure for employers who are self insured or on behalf of group pools which offer full insurance product lines or deductible insurance product lines.
Millennium Risk Managers has a solid working relationship with all major reinsurance carriers and is an approved third party administrator for virtually all reinsurance carriers.
CLIENT TRAINING
Millennium Risk Managers insists on providing training to its clients so that proper reporting of claims procedures are maintained and implemented and most importantly to give training to management and supervisors as to specific claims programs that need to be implemented and understood so that the exposure level is minimized before the claim ever occurs.
Additionally, our system will help develop an action-item list and strategies, to streamline procedures and to identify areas that are hot button issues for the claims management process.
The above process helps to identify supervisory level participation in the claims reporting process as well as the claims investigation process and assists in making the supervisor of a particular department responsible for safety issues, reporting issues, and first-line safety investigation issues. It makes the supervisor responsible for that department’s cost figures.
A primary training process offered by Millennium Risk Managers is a series of programs that ensure that the tricks of the plaintiff’s bar in the State of Alabama cannot be initiated in the beginning of the claim. These programs make sure that the claimant will have to go to the selected medical vendors prior to the claim ever occurring.
The State of Alabama is one of only a few in the United States of America that grant to the employer the right to designate the treating physician and this is the critical component of every self insured program to minimize the exposure level of any claim.
CLAIMS ADMINISTRATION SERVICES AND FEES
Millennium Risk Managers provides the following services. The services are as follows:
1. To establish a file with respect to each claim.
2. To investigate all claims and to recommend the amount of loss reserve to be established with respect to each such claim.
3. To provide each claim file with a written chronology of all actions taken with respect to the underlying claim.
4. To furnish all claims forms necessary for proper claims administration.
5. To adjust, settle or resist all claims within the discretionary settlement authority limit of the account as agreed upon by the client.
6. To adjust, settle or resist all claims in excess of the authority limit with the express prior approval of the account.
7. To supervise all litigation and other proceedings involving any claim and where permitted, to attend any judicial or administrative hearing involving any claim.
8. To monitor all treatment programs recommended to a claimant by the care provider.
9. To furnish to the client and/or its designees on a monthly basis, a “Loss Run” and a “Loss Fund Activity Report”.
10. To input any and all medical vendor payments and to pay the same according to the Alabama State Fee Schedule or the AlaMed Fee Schedule whichever is lower
11. To pay all indemnity payments and settlement payments and vendor payments (excluding medical vendors).
12. Agrees to comply with all the requirements of the Alabama Workers Compensation Laws as such requirements relate to Millennium Risk Managers in the responsibilities it is undertaking under the agreement.
13. To pursue all subrogation recovery efforts up to the necessity of litigation or the filing of any court appearance
14. Monthly check registers and cumulative loss reports with balance sheets
15. Quarterly and annual reports to the State of Alabama Department of Industrial Relations Workers Compensation Division
16. Attend and conduct monthly claims meetings
17. Attend all mediations as requested by The account Administrator
CURRENT PENDING RUNOFF FILES AND CLAIMS DATA PRICING
Millennium Risk Managers has extensive experience in taking over existing claims that are handled by a non-related third party administrator. The account or self insured company’s leadership must decide whether to allow the previous claims administrator to maintain the existing claim files or to allow those claim files to be taken over by a new claims administrator. There are positive and negatives for either decision.
SUBROGATION RECOVERY
Millennium Risk Managers’ General Counsel provides oversight and initial pursuit of all subrogation interest; however, in the event litigation must be initiated or in the event any type of court appearance must be filed to protect the subrogation rights of the account and the self insured company, Millennium Risk Managers’ General Counsel will advise the account Administrator and/or the self insured company’s representative of that necessity to employ outside counsel and the account Administrator will make the final decision as to whether or not the account’s litigation attorney can be retained for the sole purpose of initiating legal proceedings to protect the subrogation interest of a particular case.
This service is included in the proposed service fee.
EXCESS CLAIM REIMBURSEMENT SUBMISSIONS
Millennium Risk Managers’ staff also pursues all reimbursements from the account’s reinsurance carrier and maintains all financial records for all excess claims and reimbursements for the financial department of The account.
At Millennium Risk Managers we have taken the necessary steps to offer our clients the opportunity to provide their employees with the highest level of medical care for their injuries while at the same time ensuring that this care is provided at the lowest possible cost.
Millennium Risk Managers is a founding member of AlaMed, the largest workers compensation preferred provider organization in the State of Alabama. Our accounts enjoy the reduced medical costs obtained through the AlaMed PPO at no additional charge to our accounts. This feature saves huge dollars on the catastrophic claims and is an added value/feature of our services to our accounts.
This access to the AlaMed PPO and the bill adjudication process to reduce the billed charges to the AlaMed Fee Schedule is included in the proposed claims administration fee and is at no additional charge to the account.
PHARMACEUTICAL COST CONTAINMENT PROGRAM
Millennium Risk Managers Pharmaceutical Program requires the account Administrator to retain two outside vendors. The outside vendors recommended for this program implementation is Dr. Tim Covington (Former President of Samford University School of Pharmacy) and a pharmaceutical formulary supplier with pharmaceutical card programs.
To have a complete pharmaceutical management program, the program must encompass four areas. They are:
1. Price reduction per prescription below the State Fee Schedule (Pharmaceutical Cost Containment Program Medical Pharmaceutical Formulary)
2. A pharmacist in charge of drug prescription reviews
3. Generic brand program
4. Off-label use review
Overall, the program works very smoothly. The claims management team will establish, on a case by case approach, which files need to be directed into the full pharmaceutical management program. This file is then sent to Dr. Covington who reviews the file and prescriptions for the medical necessity of the prescription as well as review for the relationship of the prescription to the injury and to ensure that the drug is approved by the FDA for the primary medical purpose for the prescription. After review, he generates a report back to the claims management team and sends a letter to the doctor with any questions that may arise during this review.
If the doctor is prescribing a drug that has a generic equivalent Millennium Risk Managers sends out a series of letters that are as follows:
1. GENERIC PROGRAM
A. Letter to the doctor informing him that from a certain time period forward The account will only pay for the generic equivalent.
B. Letter to the employee informing him that from a certain date forward, we will only reimburse and pay for the generic equivalent cost and that if the employee chooses to continue with the brand name drug, that the employee will be responsible for the difference in pricing.
C. The pharmaceutical cost containment program will send out an electronic communication to the pharmacists informing them that on the next prescription forward the reimbursement will only be made at the generic pricing.
2. OFF-BRAND AND/OR NO RELATIONSHIP PRESCRIPTIONS
If Dr. Covington’s report indicates off-brand use (Neurontin etc), and/or that the drug does not relate to the injury and the doctor does not change the prescription after receipt of Dr. Covington’s letter, then the adjuster has the file put into the administrative rules for utilization review wherein the drug prescription is sent to Genex, a utilization review company for peer-review to have a legal determination that the drug is not related to the injury. (The fee for Dr. Covington’s review and the fee for Genex’s peer-review are paid out of the claimants file and are funded by The account; however, the adjuster’s participation is included in the fee).
If the review comes back in The account’s favor, we then send a letter to the doctor and the claimant informing them that the drug has been determined, under the utilization review administrative rules, as not medially necessary and therefore that particular drug will not be paid under the work comp statute. (The fee for Genex’s utilization review is a separate charge outside of this proposal and will be paid through the claimants file and funded by The account; however, the adjuster’s participation is included in the proposed service fee).
3. PRICING
Millennium Risk Managers will effectively implement any pharmaceutical cost containment program as directed by the account administrator and will work with any cost containment group as directed by the account administrator.
Millennium Risk Managers has extensive experience in pharmaceutical cost containment and currently has the following available to any pool that is being administered by MRM.
A. Millennium Risk Managers is in the process of negotiating a new cost containment prescription contract; however, MRM has combined its purchasing power with the other AlaMed pool participants to obtain a substantial cost reduction.
B. When the First Report of Injury is received by Millennium Risk Managers a copy is immediately sent to the pharmaceutical cost containment company as directed by the account administrator. This cost containment company will then issue a card for the employee to utilize.
C. The card is accepted at virtually every pharmacy in the State of Alabama including all of the major retail pharmacy chains. (This is crucial because if the account administrator allows the employee to go present the prescription to the pharmacist and pays for the prescription, The account will have to reimburse the employee and the employee will have paid the full retail value for that one prescription and no cost savings can be captured).
D. The pharmacy will fill the prescription and charge the negotiated contractual price for the drug (this is at a substantial reduction over the retail value of the drug as well as the Alabama State Reimbursement Fee Schedule).
E. Once a month, the pharmaceutical cost containment company will submit, by claimant, by prescription, a reimbursement check to pay for the dispensed drug at the pharmacy.
F. The pharmaceutical cost containment company’s reimbursement is paid out of each individual’s specific claimant file so that The account Administrator can maintain a full pharmaceutical cost tracking analysis, cases by case, department by department, injury by injury or by body part.
G. NOTE – The pharmaceutical cost containment company’s drug card only works for the most common prescribed workers compensation drugs in the State of Alabama and it prohibits the employee from duplicate prescriptions, i.e., if the employee gets a prescription of Lortab from the authorized treating physician for 30 days and uses the card to obtain the same and then, 7 days later goes to emergency room or a personal physician (unknown to all of us) and gets another prescription for Lortab for 30 days and goes to a pharmacy and tries to utilize the card for the second, unauthorized prescription, it will be declined and a note will be e-mailed to both The account Administrator and Millennium Risk Managers. Of primary importance are the new claims that are coming out of the Plaintiff’s Bar, wherein the Plaintiff’s attorneys are attempting to sue the self-insured employer for pharmaceutical drug addiction by the employer’s work comp claimants. This program exercises due diligence to prohibit the employees from becoming addicted, absent the doctor’s over-prescription methods to which we see as a common practice in the State of Alabama.
SITE SPECIFIC PPO LIST
Millennium Risk Managers implements a management medical protocol which identifies all vendors which will be utilized by our program including surgeons, gatekeepers, outpatient diagnostic centers, specific pharmacies, etc. These policies are encompassed in the following.
MANAGEMENT MEDICAL PROTOCOL
As the law is currently written, the only right available to the employer in a workers compensation case is to choose the physicians, by whom the employees are treated for their injuries. We take full advantage of this right by encouraging our clients to implement a management medical protocol. This simple document specifies not only the initial treating physician for any injury and specific emergency room for any after-hours injuries, but also designates potentially needed specialists (e.g. neurosurgeons and orthopedists).
Once our client selects their chosen doctors, a representative from Millennium Risk Managers meets with the initial treating physician and the emergency room to ensure that they will cooperate in implementing our clients’ desires as outlined by the protocol.
The trick utilized by the plaintiff’s bar in the State of Alabama to move away form the employer’s chosen physician and to get the employee to a plaintiff oriented doctor is to have the employee go to the emergency room after hours or on the weekend and have the emergency room physician refer the employee to the attorney’s doctor or to the employee’s family physician. Once this trick has been implemented, the disability of the employee and the duration of off time status are now totally in the hands of the plaintiff attorney. To eliminate this trick, Millennium Risk Managers has developed an Emergency Room Protocol that is put on file with the designated emergency room to ensure that this trick cannot be played against The account in the claims administration process.
This emergency room protocol is also important because it eliminates the following problems:
1. Medical treatment by an unauthorized doctor (stops an employee from going to his/her family physician and stops an authorized physician from making a referral to a specialist who has not been approved)
2. Unauthorized prescriptions (some employees wait until the authorized treating physician’s office is closed and will then go to the emergency room where they obtain a prescription for additional pain medication). This protocol only authorizes the emergency room to issue enough medication to get the employee to the next business day. The ER is instructed to refer the employee to the authorized primary treating physician to obtain a full prescription and to receive any needed follow-up care.
3. Unauthorized referral by the ER (stops the nighttime injured employee from going to the emergency room and then having the ER physician refer him/her to an unauthorized physician).
On numerous occasions, employees from the accounts have gone to multiple emergency rooms in an attempt to bypass standard medical protocols. The standard response from such an employee is that no one informed them that they could not go to any emergency room of their choice. Correspondingly, we have developed and will implement an Employee Downline Sheet (It is suggested that this employee downline sheet be placed in all employment application packages) wherein the employee is informed of the authorized doctor and the authorized emergency room.
The medical protocol is very flexible. If at any time our client becomes dissatisfied with a chosen physician, another is simply chosen. Once the medical protocol is in place, we inform the employees of the location to report to for medical treatment if and when injured. The rest of the treatment process, including referrals, is already understood by all parties in advance. The medical protocol is extremely useful in late reporting situations. As a general rule, when the account is late in reporting the first report of injury to Millennium Risk Managers, we are not able to obtain correct medical management from the outset. The medical protocol assists in eliminating this problem because the employee is already being directed to the appropriate medical facilities and medical providers.
It is not prudent to pre-select these physicians because the selection of the physicians and of the surgeons is the critical cornerstone of the financial integrity of the account’s workers compensation exposure level. Do not forget that this one right given to the employers in Alabama i.e., the ability to choose the physician is critical and Alabama is one of only a handful of states in the Nation that grants to the employer this right.
Correspondingly, the selection of surgeons and a complete review of which hospitals these selected surgeons have admission privileges is critical to the overall cost containment program to ensure that we fully utilize the hospitals and corresponding medical vendors that have special pricing contracts within the AlaMed PPO program.
This selection process must be a claims team process which includes the adjuster, case management nurse, the human resource director, Millennium Risk Managers’ general counsel and most importantly, the chosen litigation counsel for the account. This is the first order of business i.e. the selection of the physicians at the first meeting of the “Claims Management Team”.
THREE POINT CONTACT
Millennium Risk Managers’ standard operating procedure and best practice requirement is for the adjuster to make a three point initial contact so that an immediate fact finding telephone call is made on all loss time claims.
The three point contact encompasses the following:
1. Initial call to the employer that the claimant remains and is off work to obtain necessary background information (the date of this call is logged into the file)
2. Initial call to the employee to obtain background information and to confirm that the employee is at home or at the doctor while off work (the date of this call is logged into the file)
3. Initial call to the gatekeeper to verify off work status (the date of this call is logged into the file)
Millennium Risk Managers through its years of experience is a believer that telephonic case management is a waste of the client’s money. In the event the account Administrator is a believer in telephonic case management, we will outsource that telephone case management service to any vendor selected by the account Administrator. It’s our opinion that that type of service does not give any true savings or clarification of facts at all.
In the event the specific case warrants an investigation, Millennium Risk Manager’s best practice procedures brings that to the forefront immediately by the review of the claim at the outset by Millennium Risk Managers’ general counsel.
MEDICAL CASE MANAGEMENT VENDORS
Millennium Risk Managers works with virtually every case management company in the State of Alabama. Like all outside vendors, The account Administrator will determine the vendor; however, in the event The account Administrator requests guidance or Millennium Risk Managers’ experience on which vendor is most effective, we will be glad to provide the same; however, depending upon the injury and the catastrophic nature of the injury will determine which individual case nurse i.e. not case management company is the most effective in dealing with that type of injury and that particular physicians’ treatment for that particular injury. The claims process has to be that minutely detailed on a case by case approach to ensure the account’s financial integrity of its workers compensation exposure level.
TECHNOLOGY
CLAIMS REPORTING OPTIONS
We implement a standard claims reporting procedure of either mailing in the First Report of Injury (the least desired method), faxed into the office, e-mailed into the office (the most preferred method), or telephonic reporting through a claims telephonic claims reporting service known as QRM for a fee of $18.00 per claim reported (this charge is paid on the claim’s file and funded by The account).
ON-LINE OPTIONS
There is a possibility of obtaining an off-site license from Riskmaster that will allow The account’s representative to come into the system for view only purposes. This will allow The account to examine all adjuster notes and executive summaries together with all payment history data bank sheets. The account would pay for the actual charge of this license which is unknown at the time of this proposal.
STANDARD AND OPTIONAL LOSS REPORTS
Millennium Risk Managers will provide to the account, the following standard reports
1. Monthly check registers and cumulative loss reports with balance sheets
2. Quarterly and annual reports to the State of Alabama Department of Industrial Relations Workers Compensation Division
EMAIL RESTRICTIONS
There are absolutely no restrictions on communicating with the adjusters for The account Administrator and we encourage multiple daily communications, not only with the adjuster; but also, the accounting department, the legal staff, the I.T. staff as well as Tom Roper for trouble shooting and legal issues.
SPECIALIZED CODING
The claims data system is extremely flexible and has the capability of multiple unlimited supplemental fields for the capturing of specific loss data that is not already captured by the system.
DETAILED LOSS RUNS
All of these reports are standard reports that are provided monthly to the account at no additional charge.
CHECK REGISTERS
Millennium Risk Managers can provide check registers as requested at no additional charge. There will be one check register submitted to The account Administrator each month.
ADMINISTRATIONS
BANKING SERVICES
Millennium Risk Managers will set up the check printing system in Riskmaster so that checks can be printed for payment with a logo established by The account Administrator so that the checks will appear and be referenced to The account’s workers compensation program. There is a one-time charge for the setting up of this check template.
The account Administrator is responsible for opening up and owning the claims fund checking account because Millennium Risk Managers does not want to own any asset or appear to own any funding mechanism associated with The account’s financial exposure obligations.
All of the checks for the account administrator’s Alabama workers compensation obligations will be printed here at Millennium Risk Managers on check stock created by Millennium Risk Managers payment system that corresponds to the account’s claims fund checking account which will be owned and maintained by the account’s finance department.
DENIAL OF CLAIMS
Millennium Risk Managers’ in-house counsel will submit a request for denial of a claim to The account Administrator. This request will be e-mailed or faxed together with a follow-up phone call. The written information will contain all pertinent event facts, investigation facts, and the application of legal theory for the appropriate Alabama Workers Compensation Code Sections and/or Case Law to support the position that the claim is deniable under the Alabama Workers Compensation Statute.
The decision to deny is a joint decision made by the designated members of the claims team and should always include The account’s chosen litigation attorney.
Do not ever forget the plaintiff’s litigation atmosphere in the State of Alabama. All decisions of denial of a claim, whether it is in whole or in part, should always include the opinion of the outside litigation attorney.
These issues are addressed in the proposed monthly claims meetings.
HEARINGS, MEDIATIONS, OR TRIALS
It is the sole responsibility of the chosen litigation attorney to communicate with both Millennium Risk Managers’ legal staff and The account Administrator in regards to trial dates, hearings, and court ordered mediations.
It is the sole responsibility of Millennium Risk Managers’ litigation staff to recommend cases for mutually agreed upon mediations and Millennium Risk Managers in-house attorneys will participate in all of these non-litigated court ordered mediations. This service is included in the proposed fee. Millennium Risk Managers’ litigation staff will also participate in all litigated court ordered mediation as requested by The account Administrator and this service is included in the proposed service fee as well.
These issues are addressed in the proposed monthly claims meetings.
SURVEILLANCE REQUESTS
Prior to any surveillance or private investigator being retained for any claim, the adjuster must fill out a “Surveillance Request Form” which contains the reasons for surveillance, the recommended surveillance company and the estimated cost. This form is then submitted to Millennium Risk Managers’ in-house counsel for his review. If the legal department agrees, it is then e-mailed to The account Administrator with a follow-up phone call to personally discuss this request.
It is important that surveillance be conducted by an outside source that is not related in business entity format to either MRM or The account due to liability issues as well as credibility issues at trial.
These issues are addressed in the proposed monthly claims meetings.
SETTING OR INCREASING RESERVES - $25,000
It is the core responsibility of Millennium Risk Managers to provide an accurate total incurred exposure to the finance department of The account and it is extremely dangerous for The account Administrator to retain the absolute right to establish the reserves because the excess carrier does not like internal reserve setting by the account and the actuaries must establish the incurred but not reported reserves for the finance department will double this reserve in the event that “step-reserving” is identified from an historical perspective.
One of the best attributes that Millennium Risk Managers brings to the table is an extremely accurate ultimate total loss reserve and we do not believe in step-reserving.
Millennium Risk Managers’ standard procedure is to have a claims team reserve audit one time a year during the month that The account’s financial fiscal year ends. At this meeting, we go over all pertinent facts as known at that time and we either increase or decrease the outstanding reserves so that the finance department can have an accurate ultimate reserve figure to place on The account’s end of the year financial statements as a “contingent liability footnote to the financial records”.
Also, all reserves are examined by the claims team monthly at the proposed monthly claims meeting so that there is, as accurate as possible, monthly reserve figure maintained at all times that are based upon current known facts.
Also, as Millennium Risk Managers’ best practice, the adjuster must fill out a reserve increase sheet and present the same to the senior claims supervisor for review prior to any discussions beginning on the increase in the reserve amount.
NOTE: BOTTOM LINE, THIS AREA OF THE CLAIMS ADMINISTRATION IS EITHER STABLE OR FRAGMENTED AND IT MUST BE ESTABLISHED AND MAINTAINED AS A STABLE FIGURE FOR THE OUTSIDE FINANCIAL AUDITOR. THE ACTUARY, THE FINANCE DEPARTMENT AND THE REINSURANCE CARRIER AND THIS SHOULD BE A CLAIMS TEAM ENDEAVOR, I.E. NOT 0NE INDIVIDUAL’S DECISION.
CLAIMS SETTLEMENT
The adjuster, prior to making any offer to settle, fills out a “Settlement Authorization Form” and submits the same to Millennium Risk Managers legal staff for review. This review encompasses all details and positions that can be maintained during settlement negotiations to ensure that we only pay that which is justified.
If Millennium Risk Managers’ legal staff is in agreement with the settlement request, this form is then e-mailed or faxed to the account administrator or pool administrator’s representative together with a follow-up phone call to discuss the settlement authority request.
This form contains all pertinent event facts, medical procedure facts, physical restrictions and ultimate medical ratings and vocational ratings. This form then gives a ceiling value and a floor value if the employee is allowed to return to work, i.e., accommodated and it gives a ceiling value and a floor value in the event the employee cannot return to work, i.e., not accommodated.
This form then gives a requested ultimate settlement value request to which is either, authorized, altered, or denied by The account Administrator.
These issues are generally covered in the proposed monthly claims team meeting.
ASSIGNMENT OF MEDICAL CASE MANAGEMENT
The adjuster, prior to making a case management assignment, must fill out a “request for case management form”. This form lists the proposed case management nurse or company together with the pertinent facts justifying the requests. This form is sent directly from the adjuster to The account Administrator (it does not go to Millennium Risk Managers legal department).
The account Administrator will then consider the request and either approve or deny the same.
TRANSITIONAL LIGHT DUTY PROGRAM
This program is extremely important in that it is in writing.
If this program is not in writing, the account has set itself up to be sued for Wrongful Termination and for violating the Americans with Disabilities Act.
This program caps the duration or time period of light duty programs.
If this program is not in place and in writing and an employee has an injury (but not at MMI) and the doctor temporarily returns him back to work light duty an the employer accommodates him by giving the employee a very low, low, low impact job duty that is not truly within a job description and the employee stays at this job for a length of time and then the doctor places the employee at MMI with the same restrictions but now they are classified as permanent, and the employer at that point informs the employee that they cannot permanent accommodate the employee with this low, low, low impact job, the employee will sue for (1) Wrongful Termination and (2) violating ADA. It is important to note that it is very hard to take the position of substantial hardship at the ADA trial when the employer has been voluntarily making the accommodations all along.
This document minimizes liabilities that attach as much as possible in the State of Alabama and in Federal Court.
Our number one goal is to take care of our clients’ employees that are truly injured while on the job. Unfortunately, significant abuses sometimes occur. Our clients deserve the best possible assistance in dealing with problem or exaggerated claims. We at Millennium Risk Managers are firm believers in the selective use of surveillance on such claims. We have literally saved our clients millions of dollars in abuse cases by successfully utilizing surveillance.
Surveillance is used primarily in two instances:
1. A negative diagnostic test with continued complaints of pain.
A negative diagnostic test (e.g. an MRI, CAT scan or myelogram) indicates a non-severe injury. Depending upon the type of injury involved, our adjusters know the maximum reasonable time that the employee should require treatment or need to be excused from their job. After this period of time has elapsed, if the employee is still complaining, seeking treatment or attempting to be excused from their normal job duties, surveillance is in order.
2. Whenever our client desires its use.
Surveillance is also utilized any time our client requests its use. After all, our clients know the individual employees far better than we do and therefore have a better insight into their particular claims.
Millennium Risk Managers’ adjusters fax a “surveillance authorization” form to our account’s representative giving detailed reasons why we believe surveillance is warranted. The account makes the final decision and sets the dollar limit that can be expended on the surveillance request. This type of detail assures the account’s complete control and direction over their claims (This process is also implemented for on-site medical case management)
Millennium Risk Managers has effectively utilized surveillance companies over the past ten years and we know which surveillance companies are productive. We have the surveillance companies that we utilize on a regular basis provide $1 million dollars in liability coverage and we require our accounts to be added as additional insureds. We are flexible in that we can work with any surveillance company or case management company that the account wishes to utilize in the conducting of their business.
In the event that you choose the services of another TPA, make sure that this new TPA requires its surveillance companies to name the account as an additional insured on their liability policies. Do not fall into the trap of letting the TPA convince your company that you are covered if you are named as a certificate holder on the surveillance company’s general liability policy.
Likewise, the adjuster must obtain approval from the decision-maker for the placement of case management on a file. This is accomplished by sending to the account, a document detailing the reasons why case management is warranted. The account makes the final decision and either approves or denies the request.
In regards to settlements, the account is sent a “Settlement Authorization Request” in which detailed information is provided, including exposure levels. The account either approves or denies and gives specific instructions as to the account’s desire and direction.
The above-referenced procedures are excellent tools for management control and serve as a foundation for accurate claim file audits by the account.
We spend a great deal of time and effort closely examining diagnostic test results looking for signs of degenerative back disease. While it is true that if we exaggerate an existing condition such as degenerative back disease, we are responsible for treatment, it is important to get the physician to distinguish between a temporary or permanent aggravation of this degenerative condition. A temporary aggravation indicates that we are only responsible for our aggravation, and not responsible for treating the degenerative condition itself. Many surgeries can be avoided under workers compensation by getting the treating physician to make this important distinction when possible.
COMPUTER SUPPORT AND RISK MANAGEMENT INFORMATION SYSTEM
Millennium Risk Managers will provide monthly loss data as follows:
1. Monthly Check Registers detailing all payments made during any given month, whether medical or indemnity, identifying claimant and payee.
2. Cumulative Employer’s Report indicating the amounts that have been expended to date, outstanding reserves, total incurred losses to date by individual locations.
3. Individual Employer’s Report detailing each location’s claims by employee. This report specifies claim type, claim status, injury date, part of body injured, cause of injury, type of injury as well as payments made during the month, payments to date, reserve balances and total incurred in regards to compensation, medical rehab, and other expenses.
Millennium Risk Managers can also provide specialized reports based upon the requirements of the account. Examples are as follows:
1. Claims Analysis by Body Part – this specialized report indicates the total dollars incurred for all injuries by specific body parts.
2. Claims Analysis by Nature of Injury – this specialized report indicates the total dollars incurred by types of injury.
3. Claims Analysis by Cause – this specialized report indicates the total dollars incurred by immediate cause and basic cause.
Our computer automatically re-prices all medical bills to the State Fee Schedule at no additional cost to our clients. At any time, we can provide our clients with reports detailing each medical bill and the actual dollar savings that have been provided by our Millennium Risk Managers re-pricing system.
LEGISLATIVE SERVICES
Due to the accounts presently represented by MRM, we do extensive work in the Legislature in the form of (1) drafting workers compensation legislation, (2) reviewing workers compensation legislation and (3) testifying before House and Senate subcommittees in regards to compensation legislation affecting the employers operating within the State of Alabama.
As a result, MRM has the ability to know, (before the general employee population), all statutory movements passing through the Legislature. This has proven extremely valuable to our accounts. Likewise, we are able to solicit the assistance of other association and employer lobbyists to further advance legislation favorable to MRM’s accounts.
CLAIMS ADMINISTRATION SERVICES
Millennium Risk Managers proposes a one-time charge for loss time, medical only and medical record only files. In the event medical only files remain active over an 18-month period, the price is readjusted. The following is the basic services:
1. To establish a file with respect to each claim.
2. To investigate all claims and to recommend the amount of loss reserve to be established with respect to each such claim.
3. To provide each claim file with a written chronology of all actions taken with respect to the underlying claim.
4. To furnish all claims forms necessary for proper claims administration.
5. To adjust, settle or resist all claims within the discretionary settlement authority limit of Service Company as agreed upon by the client.
6. To adjust, settle or resist all claims in excess of the authority limit with the express prior approval of the client.
7. To supervise all litigation and other proceedings involving any claim and where permitted, to attend any judicial or administrative hearing involving any claim.
8. To monitor all treatment programs recommended to a claimant by the care provider.
9. To furnish to the client and/or its designees on a monthly basis, a “Loss Run” and a “Loss Fund Activity Report”.
10. To input any and all medical vendor payments according to the payments reflected by Blue Cross/Blue Shield.
11. To pay all indemnity payments and settlement payments and vendor payments (excluding medical vendors).
12. Agrees to comply with all the requirements of the Alabama Workers Compensation Laws as such requirements relate to Millennium Risk Managers in the responsibilities it is undertaking under the agreement.
13. Agrees to furnish the account with monthly printout statements showing analysis and statistical studies covering claims filed against the employer.
COURTEOUS PROFESSIONALISM
We at MRM pride ourselves on working hand-in-hand with self-insured employers and group pools in administering their workers compensation program. We are adept at setting up customer specific requirements on how you want us to handle your claims, incorporate your rollover requirements of existing claims, and meet your excess carrier/re-insurance requirements. We assist our customers in establishing a medical protocol program consisting of management, emergency room, and employee procedures.